A psychiatrist with the VA in Brockton told federal officials that three patients received poor mental health care.

BROCKTON – A veteran diagnosed with paranoid schizophrenia was given an inappropriate amount of medication for years at the Brockton Veterans Affairs Medical Center before his death, according to a federal whistleblower.

The allegation by a VA psychiatrist working in Brockton – who revealed two other cases of neglect substantiated by federal investigators – has not been publicly disclosed until now.

It is included in a report obtained this week by The Enterprise that was sent from the Office of the Medical Inspector – part of the Veterans Health Administration – to the U.S. Office of Special Counsel.

The redacted copy of the report, dated Jan. 2, 2014, reveals new details about the two patients previously described and reveals the third allegation, not substantiated by investigators.

In June, information provided by the Brockton whistleblower on the mental health care of the two other veterans was included in a letter sent from the Office of Special Counsel to the White House.

The office has reviewed dozens of cases of patient neglect at VA facilities nationwide. The investigations come amid a national scandal prompted by reports of patients dying in Phoenix while waiting for medical appointments.

In the January report, the whistleblower told investigators that the patient with schizophrenia was given benzodiazepine, a psychotropic medication “for more than two years without any attempt to decrease or discontinue use, when specific clinical directions and indications stated that this medication should not be given to this individual.”

Investigators said they did not substantiate the allegation because from 2010 to 2012 the veteran’s benzodiazepine dosage was reduced by 50 percent. The veteran later died from an unrelated condition.

His date of death, the three patient identities and the identity of the whistleblower were redacted from the report.

All three patients spent time in the Community Living Center, a long-term care facility at the Brockton VA facility on Belmont Street.

The two earlier cases of neglect involved an Army Green Beret with post-traumatic stress disorder and an Army combat veteran of Vietnam with “major depression with psychotic features.”

The Green Beret veteran was diagnosed with Parkinson’s Disease in 1993 and had been treated over the years for “confusion, depression, PTSD, dementia, psychosis, visual hallucinations and suicidal ideation.”

He did not undergo “a significant psychiatric consultation” for eight years while in Brockton and later died as a result of his Parkinson’s Disease. The date of his death was redacted from the report.

The Vietnam vet had a history of suicide attempts. He has been a patient in Brockton since 2003. From June 2005 to May 2013, the report showed he had one psychiatric note written in his medical chart.

In each case, the diagnoses for these veterans showed that their maladies were 100 percent service-connected.

Dr. Michael Charness, Chief of Staff of the VA Boston Healthcare System, said in a statement Friday that the two previously described patients each had more than 2,000 notes in their medical charts and “were under the continuous care of a geriatrics team” that included physicians, nurses, a full-time psychologist and other health care staff.

He also stressed that the “report concluded that there was no violation of statutory laws, mandatory rules, or regulations, and no adverse outcomes of care were identified.”

“(The Office of the Medical Inspector) did identify some opportunities for improvement in the care of long-term residents with certain psychiatric diagnoses or medications, including scheduling at least annual psychiatric evaluation, rather than depending on the nursing home psychologist or physician to recommend psychiatric consultation as needed,” Charness said. “All of the OMI recommendations have been fully implemented.”

Joseph Markman may be reached at jmarkman@enterprisenews.com.

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